- Copyright © 2010, The American Academy of Pediatrics
by Deborah Johnson - Correspondent
Babies should be screened at 12 months of age for iron deficiency and iron deficiency anemia under new AAP recommendations aimed at preventing long-term neurodevelopmental problems.
An AAP clinical report being early-released, Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children 0 Through 3 Years, http://pediatrics.aappublications.org/cgi/content/abstract/peds.2010-2576v1, also will appear in the November issue of Pediatrics. The report contains, for the first time, AAP recommendations for iron supplementation; it is a revision and extension of the 1999 policy on iron fortification of formulas.
Need for universal screening
Although no study definitively has shown a connection between iron deficiency and lowered IQ, enough evidence exists to recommend universal screening, according to the clinical report’s co-authors, Robert D. Baker Jr., M.D., Ph.D., FAAP, and Frank Greer, M.D., FAAP.
"There is growing evidence that iron deficiency and iron deficiency anemia have long-term effects on behavioral and neurodevelopmental issues that can appear one to two decades after the anemia is treated," Dr. Baker said.
Dr. Greer agreed. "Even though the evidence is not solid, it would potentially cause so much harm that (we decided) we should go ahead and test for iron deficiency in kids," he said.
Lack of iron is the world’s most common nutrient deficiency. In the United States, the problem has been abated with use of iron-fortified cereals and formulas. Nevertheless, certain U.S. populations remain at risk, including babies who exclusively breastfeed after 4 months of age, preterm infants, children with special health care needs, kids from poor families and Mexican Americans. More than 9% of the U.S. population is iron deficient.
In addition, a child need not be anemic to suffer from a detrimental iron deficiency, according to Dr. Greer. Animal studies have shown iron, when deficient, is conserved for the blood at the expense of the brain. That means the deficiency won’t always be detected with a simple hemoglobin test.
"By the time you develop anemia, you’ve been iron deficient for a while," Dr. Greer said.
The only way to identify all children with iron deficiency would be to draw blood from a vein for an analysis. However, Dr. Greer said, members of the AAP Committee on Nutrition were concerned that would be too invasive and expensive.
As a compromise, the committee elected to recommend a finger prick at 12 months of age to test for hemoglobin only. Pediatricians then should assess the patient’s risk factors for iron deficiency to determine if further testing is needed.
One side benefit to this compromise is that children suffering from anemia unrelated to iron deficiency also will be identified, Drs. Greer and Baker said.
In addition to universal screening, the report recommends the use of iron supplements for breastfed infants beginning at the age of 4 months.
The physicians explained that full-term healthy babies receive enough iron from their mothers in the third trimester of pregnancy to last for the first four months of life. However, human milk contains little iron, so infants who are exclusively breastfed are at increased risk of iron deficiency after 4 months of age.
The clinical report recommends giving breastfed infants 1 mg/kg/day of a liquid iron supplement until solid foods, such as iron-fortified cereals, are introduced. For partially breastfed infants, the iron recommendation remains the same as that for fully breastfed infants if more than half of the daily feedings are from human milk and the child is not receiving iron-containing complementary foods.
The iron needs of formula-fed infants can be met for the first 12 months of life with standard infant formula and the introduction of iron-containing foods, such as baby cereal. The report emphasized that whole milk should not be given to infants under the age of 12 months. Dr. Baker noted that in tough economic times, parents are tempted to start cow’s milk earlier.
"We do see kids getting a lot of cow’s milk and are iron deficient from that," he said.
One recommendation may change the order in which solid foods are introduced. Traditionally, iron-rich meat is the last food introduced to infants, preceded by cereal, fruits and vegetables. This sequence, however, has not been scientifically tested. Dr. Baker said that food order should be reversed. Red meat and vegetables with higher iron content should be introduced into the baby’s diet early on, perhaps at 6 months of age.
According to the report, children between the ages of 6 and 12 months should receive 11 mg of iron each day. Toddlers up to age 3 should receive 7 mg a day. That iron is best delivered by eating red meat, iron-fortified cereal, vegetables containing iron and vitamin C, which augments the absorption of iron.
The iron intake of toddlers being raised vegetarian should be monitored closely. Iron-fortified cereals and beans can help provide the needed iron.
Still, said Dr. Greer, "You have to eat a lot of black beans to get the equivalent of a serving of red meat."